How to use it
Pick the stage first. Pregnant needs a due date or a gestational age: the tool will not guess one, and it rejects dates that cannot be a current pregnancy. Tick every IBD medicine (or “No IBD medicines”) and every surgical or perianal feature (or “None of these”), so a blank is never read as “no”.
Each line in the plan carries its source. GRADE n is one of the consensus’s 34 GRADE recommendations, with its strength and certainty. Consensus statement n is one of its 35 RAND statements, which are expert agreement without a GRADE rating. “Table 5/7/8/9” are the consensus tables.
Key points from the 2025 Global Consensus
| Topic | What the consensus says |
|---|---|
| Before conception | Documented remission, ideally 3–6 months, steroid-free, with normal CRP and calprotectin below 150 µg/g (CS 5, Table 5) |
| 5-ASA, sulfasalazine | Continue (GRADE 12 strong; GRADE 13 conditional). Sulfasalazine: folic acid 2 mg daily |
| Folic acid | 0.4 mg from at least 4 weeks before conception; 2 mg from 3 months before on sulfasalazine; 5 mg with extensive small-bowel disease, malabsorption or a family history of NTD (Table 5). Those at increased risk of folate deficiency continue it throughout pregnancy (text) |
| Thiopurines | Continue (GRADE 16). Do not start in pregnancy (CS 12). Check liver enzymes and metabolites (CS 13) |
| Methotrexate | Stop before conception (GRADE 15 strong): at least 1 month (Table 5), ideally 1–3 months (Table 9). Clinic practice: 3 months |
| Anti-TNF, vedolizumab, ustekinumab, anti-IL-23 | Continue throughout (GRADE 17, 19, 20; CS 17). No “last dose” week; avoid stopping |
| JAK inhibitors | Stop at least 4 weeks before conception unless no effective alternative (CS 20–21). Clinic practice: 3 months |
| S1P modulators | Ozanimod at least 3 months, etrasimod at least 1–2 weeks before conception (CS 18–19). Clinic practice: 3 months for both |
| Aspirin | 150–162 mg daily by 12–16 weeks (GRADE 9, conditional) |
| Delivery | Cesarean for active perianal CD (GRADE 10) and rectovaginal fistula (CS 10); consider with IPAA (GRADE 11). Active perianal disease flags the status line |
| VTE | Risk raised antepartum and postpartum (GRADE 25–26); prophylaxis in hospital and especially after cesarean. A previous VTE flags the status line for a thromboprophylaxis assessment with obstetrics |
| Infant | Non-live vaccines on schedule; rotavirus may be given (GRADE 33, conditional, very low); no BCG for 6 months after anti-TNF (GRADE 34) |
Rotavirus: the tool follows the consensus
The consensus suggests rotavirus vaccine may be given after in-utero biologic exposure (conditional recommendation, very low certainty), and the tool follows it. The Canadian Immunization Guide is more cautious: it says there are no data, that the decision should be an individual risk–benefit assessment (immune testing may help), and that in a province with a rotavirus program, such as Ontario, withholding may be considered. That text is older: the CIG table of updates shows it was added in November 2016, no later update changed it, and it cites no study after 2016, so it predates the Canadian cohort data (Fitzpatrick 2023) and the 2025 consensus. CAG’s 2021 guideline made no recommendation. The infant’s clinician needs to know about the exposure early, because the series cannot start at 15 weeks of age or later.
Canadian data support offering it: in the Canadian Immunization Research Network cohort of 191 exposed infants, rotavirus vaccine was recommended for 187 and there were no serious adverse events (Fitzpatrick 2023); in a Calgary cohort of 57 infants exposed to infliximab, adalimumab, vedolizumab or ustekinumab in the third trimester, immune testing was normal and 50 infants completed the rotavirus series with no adverse effects (Ernest-Suarez 2025).
BSG 2025 is more cautious. It advises withholding BCG until at least 12 months after in-utero biologic exposure and giving all live vaccines at or after 12 months, and it calls rotavirus probably low risk but of modest benefit in the UK (its summary box says rotavirus may be given on schedule after in-utero anti-TNF exposure). The tool follows the Canadian Immunization Guide and the consensus (BCG deferred for 6 months). BCG is rarely indicated in Ontario.
RSV. The Canadian Immunization Guide (September 2026 update) adds that exposed infants should receive RSV monoclonal antibody on the routine schedule, like non-live vaccines. Nirsevimab (Beyfortus) is marketed in Canada; clesrovimab (Enflonsia) is approved but not yet marketed (Drug Product Database, October 2026).
Status line
The headline reads action needed for a red alert (a drug to avoid, active disease), check items flagged for an amber one; otherwise the plan is reported as on track. Active perianal Crohn’s disease (mode-of-delivery discussion; cesarean suggested, GRADE 10) and a previous VTE (thromboprophylaxis assessment with obstetrics and haematology as needed; IBD raises VTE risk, GRADE 25–26) are amber alerts in every stage, so neither is reported as “on track”.
Monitoring in pregnancy
- Fecal calprotectin is not changed by pregnancy (Julsgaard 2017), unlike CRP, albumin and hemoglobin. Check it each trimester (Squirell 2024).
- Intestinal ultrasound is accurate in the first and second trimesters (Table 7). Terminal ileum views fall after about 20 weeks: 93% adequate before 20 weeks, 59% at 20–26 weeks (Flanagan 2020). In the third trimester it is technically challenging.
- Imaging: ultrasound or MRI without gadolinium is preferred over CT (CS 7), but CT is not forbidden when it is the right test.
Pitfalls
- Stopping biologics late in pregnancy. Older advice to stop anti-TNF at 24–32 weeks is not in the 2025 consensus, which says to continue throughout and to avoid stopping.
- Live vaccines for the mother. MMR and varicella are avoided on high-dose steroids, thiopurines, biologics or small molecules (Table 5). Plan serology early; vaccinate at least 4 weeks before starting immunosuppression or at least 3 months after stopping it (CAG 2021), and avoid conception for 28 days after a live vaccine.
- “Most IBD medicines are safe.” True for most, but never for methotrexate, and JAK inhibitors and S1P modulators are relatively contraindicated. The tool gives drug-specific advice only.
- Phthalate-coated mesalamine. Older Asacol contained dibutyl phthalate, which Squirell 2024 advised avoiding before and during pregnancy. Asacol is no longer marketed in Canada, the consensus notes that current 5-ASA formulations do not contain dibutyl phthalate, and none of the Canadian monographs for marketed mesalamine products lists it (checked October 2026).
- Washout lengths. The tool uses one stop time, 3 months before trying to conceive, for methotrexate, JAK inhibitors, ozanimod and etrasimod (Squirell 2024 and clinic practice). It is not only about drug clearance: 3 months also gives time to start a pregnancy-compatible drug and confirm that it holds remission. The 2025 consensus minimums are shown beside it (methotrexate at least 1 month, ideally 1–3 months; JAK inhibitors at least 4 weeks; ozanimod at least 3 months; etrasimod at least 1–2 weeks).
- Thiopurines: follow the consensus. The 2025 consensus (GRADE 16, CS 24) and Squirell 2024 continue an established thiopurine through conception, pregnancy and breastfeeding. The Canadian Imuran label is more restrictive; follow the IBD consensus.
- Folic acid doses differ between IBD and obstetric guidance. The tool uses the consensus doses (0.4 mg; 2 mg on sulfasalazine; 5 mg with extensive small-bowel disease, malabsorption or a family history of NTD), with at-risk patients continuing through pregnancy. SOGC (No. 427, 2022) gives a low dose to everyone through pregnancy and breastfeeding and a higher, two-period regimen for conditions with a risk of folate deficiency; its 2015 predecessor put IBD malabsorption and folate-inhibiting drugs at 1 mg until 12 weeks, then 0.4–1 mg. Squirell 2024 gave 2–5 mg on sulfasalazine from at least 1 month before conception through the first trimester. The consensus is the more generous and the longer of these.
- The risk score in the old tool was not validated and has been removed.
Newer drug data (2025–26)
None of these changes the consensus advice, but they help the conversation:
- Risankizumab: two 2026 reports found no safety signal: 444 exposed women in a US multicentre database (fewer than 10 adverse pregnancy outcomes, no preterm births; Winter 2026) and an Israeli real-world cohort with no added risk versus anti-TNF or conventional therapy (Tsur 2026). Data for mirikizumab and guselkumab remain very limited.
- Tofacitinib: in 85 maternal exposures from the clinical programs, outcomes were similar to the general population, but the authors still advise against use in pregnancy unless clearly necessary (Mahadevan 2026). The consensus washout (at least 4 weeks) is unchanged.
In Dr. Squirell’s cohort
In 291 pregnancies followed prospectively (2017–23), 74% of women were in clinical remission before conception, activity rose through pregnancy in UC (peaking at 37% in the second trimester), and continued biologic therapy did not worsen outcomes. Steroid use was linked to preterm delivery (Squirell 2025).